Many tasks require complex information acquisitions which include a series of information queries. Often, the information results obtained in response to one or more queries will affect what information queries subsequently occur. For example, a medical diagnosis may involve a physician reviewing a patient's past medical records, interviewing the patient for information about their history and present condition, conducting a physical examination, performing and/or order laboratory tests, biopsies, and other data inquiries. A medical diagnosis may be guided by certain standard inquiry sequences which are used according to established standards of care, billing guidelines, and/or other bases. Although skilled medical judgment remains central to a diagnosis, external tools and guidelines may increase efficiency, compliance with standards, and verifiability. As the use of computer-based technologies becomes increasingly common in medical practice, the need for more dynamic, efficient, and non-intrusive solutions increases.
Physicians increasingly are using electronic medical record systems (“EMR”). Notwithstanding this, the ability to capture quickly and easily a clinical note during a consultation remains a source of frustration as information overload, either consciously or subconsciously, may frequently be encountered. During a consultation the physician must socially engage with, and reassure, the patient whilst simultaneously making observations and/or requesting investigations relevant to the patient's condition. In an example of a cancer diagnosis, the physician may then consider the acquired data in order to arrive at a diagnosis. A treatment strategy may be created, involving surgery, chemotherapy and radiotherapy in any combination or permutation. In addition, each of these disciplines may require many factors to input into an effective decision making process.
Traditionally, the physician will make written notes that act as an “aids-de-memoire”, before formalizing the annotations by dictating for a transcription secretary. Many EMR systems emulate this process by providing “fields” for the required clinical elements (e.g. history of present complaint/illness, review of systems, past histories, examination findings and investigation results such as imaging, biopsy and histology findings) into which the dictated notes are transcribed.
The addition of modern computer systems into the medical field with attendant EMR systems often require the physician to acquire several new skills including typing, use of the mouse and navigation through an application. Through requiring less of the physician's attention being spent on it, a clinical information acquisition system allows the physician to dedicate more attention to the patient.